| Whitewater Oral Surgery Group Pllc | |
|
3003 W Main St Ste 130 Boise ID 83702-2026 | |
| (208) 342-7610 | |
| (208) 344-1799 |
| Full Name | Whitewater Oral Surgery Group Pllc |
|---|---|
| Speciality | Dentist |
| Location | 3003 W Main St Ste 130, Boise, Idaho |
| Authorized Official Name and Position | Kevin Glenn Kempers (OWNER) |
| Authorized Official Contact | 2083427610 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Whitewater Oral Surgery Group Pllc 3003 W Main St Ste 130 Boise ID 83702-2026 Ph: (208) 342-7610 | Whitewater Oral Surgery Group Pllc 3003 W Main St Ste 130 Boise ID 83702-2026 Ph: (208) 342-7610 |
| NPI Number | 1104248053 |
|---|---|
| Provider Enumeration Date | 01/13/2014 |
| Last Update Date | 09/04/2020 |
| Medicare PECOS PAC ID | 4789009473 |
|---|---|
| Medicare Enrollment ID | O20200928002448 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1104248053 | NPI | - | NPPES |
| 805496900 | Medicaid | ID | |
| 805511300 | Medicaid | ID |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223S0112X | Dentist - Oral And Maxillofacial Surgery | D3407 (Idaho) | Primary |
| 1223S0112X | Dentist - Oral And Maxillofacial Surgery | M7750 (Idaho) | Secondary |
| Provider Name | Paul Clark |
|---|---|
| Provider Type | Practitioner - Oral Surgery |
| Provider Identifiers | NPI Number: 1689994923 PECOS PAC ID: 1456772060 Enrollment ID: I20200608002472 |
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